Health governance in Ethiopia: Does systems theory strengthen district health planning and procedural fairness?

Author(s) Kadia Petricca1, Dereje Mamo2, Whitney Berta 3, Clare Pain 4, Jennifer Gibson 5
Affiliation(s) 1Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada, 2Policy and Planning Directorate, Ministry of Health, Addis Ababa, Ethiopia, 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada, 4Psychiatry , University of Toronto, Toronto, Canada, 5Joint Centre for Bioethics, University of Toronto, Toronto, Canada.
Country - ies of focus Ethiopia
Relevant to the conference tracks Governance and Policies
Summary Building strong health systems in resource-poor settings involves strengthening good governance. This study explores the ability of a new district-health planning strategy in Ethiopia to strengthen procedural fairness and district-level capacity, while further reflecting on the systemic features that act as barriers and facilitators in this process. Results explore various dimensions of the district-health planning process and in strengthening procedural fairness at all levels. Strengthening mechanisms for building good governance can enhance the  transparency and accountability of health systems.
Background Health planning and priority setting is a complex undertaking in all health systems. Therefore, building strong health systems in resource-poor settings involves strengthening good governance for health planners to assert their local needs, and build capacity for multistakeholder engagement, and transparent and accountable decision-making. In 2008, the Ethiopian government implemented district-based health sector planning; a national strategy to streamline evidence-based planning, harmonize stakeholder agendas and promote democratic decision-making. While evaluations revealed some improvements in these areas, they also revealed a variety of system-level constraints influencing the adoption of such processes. However, conceptual guidance in the use of systems theory and in its ability to guide our understanding of health governance and procedural fairness remains in its infancy. Using a systems analysis and a framework for procedural fairness, this study analyzes challenges and strengths emergent from implementation.
Objectives The overall objectives of this presentation will be to (i) reflect on the experiences of implementing district-based health sector planning in Ethiopia through the views of health planners and non-government partners; (ii) assess its implications on strengthening fair and legitimate decision-making; and (iii) to further reflect on the application of a systems analysis to gain a deeper understanding of important systemic factors influencing health planning and procedural fairness.
Methodology Multiple case studies were conducted in three districts (in three separate regions) of Ethiopia. Methods included: (i) Fifty-eight in-depth interviews with national, regional, and district health planners and non-government partners, (ii) participant observation in health planning meetings; and (iii) policy analysis. Analysis was guided by the Transformative Systems Change Framework (TSCF) and Accountability for reasonableness (A4R).
Results Overall, district-based health sector planning had a strong impact on strengthening both evidence-based planning and democratic decision-making. A new evidence-based planning and budgeting (EBPB) tool guided district health planners to set priorities through generating priority targets. A4R revealed the process upheld principles of fairness based on the inclusion of multistakeholder engagement, disclosure of planning outcomes, evidenced-based planning and an appeals mechanism. Leadership capacity at the district level was still considered weak and varied across districts. To guide our understanding of the system, the TSCF dissects the system structure into four components that may act as barriers or facilitators in district health planning. It identified: (I) System Norms, where strong cultural values were present for strengthening evidence-based practice and promoting participatory dialogue; (II) System Regulations, where policies and national strategies promoted and valued evidence-based planning and stakeholder inclusivity, yet did not highlight explicit mechanisms for promoting transparency; (III) System Resources, where limited technical and environmental capacity hindered the management of the excel-based planning and budgeting tool and the ability to conduct on-going training; and (IV) System operations, where on-going communication delays between district health offices and NGOs and overlapping stakeholder roles impacted the clarity and efficiency of planning. There is clear interconnectedness between each of these system elements that will be further reflected upon, for changes in one domain will yield consequences in another.
Conclusion Strengthening the capacity of district health planners to set health priorities can enhance the transparency and accountability of health systems in low-income settings. District-based health sector planning appears to be a valuable mechanism in strengthening the evidence-based planning and procedural fairness as it guides evidence-based planning through the EBPB tool and promotes democratic decision-making through multistakeholder engagement. A systems lens can reveal unique insights as to the interconnected parts of a system and how they impact the ability of district health planners to set health plans and priorities fairly, legitimately and in accordance with national policies and local health needs.

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